The unprotected exposure of a respiratory therapist who later developed bacterial meningitis has triggered the first citations under California's new Aerosol Transmissible Disease Standard. Fines of $101,485  including two "willful" violations, the strongest possible penalty – were levied against Alta Bates Summit Medical Center in Oakland, CA.

The medical center has appealed the citations, but a request for comment by the hospital had not been granted as this story was filed.

The hospital failed to promptly report the case of bacterial meningitis as soon as it was suspected in initial tests and failed to conduct a prompt exposure analysis or to readily offer prophylaxis, according to the California Division of Occupational Safety and Health (Cal-OSHA). An Oakland police officer, who was first on the scene and discovered the unconscious patient at his home, also was hospitalized with bacterial meningitis. Alta Bates Summit Medical Center has appealed the citations.

Both the respiratory therapist and police officer required intensive care unit treatment, but both survived. The case highlights the importance of a swift response to exposures and the use of personal protective equipment to protect employees from unidentified infectious diseases, says Deborah Gold, MPH, CIH, senior safety engineer in the research and standards health unit at Cal-OSHA in Oakland.

"We hope the discussion generated by this case will cause other hospitals to look at what they're doing and make sure their procedures are in place," she says. "This is a bad outcome. This could have had a much worse outcome."

Nationally, the Ryan White HIV/AIDS Treatment Extension Act of 2009 requires hospitals to notify emergency responders that they transported a patient with an airborne infectious disease. That report is supposed to occur within 48 hours of determination of the disease. The act calls for the Secretary of U.S. Health and Human Services to create a list of life-threatening infectious diseases and those that can be transmitted through the airborne route.

The Oakland case began on Dec. 3, 2009, with a call to 911. Someone had failed to show up for work, and his co-workers were concerned. A police officer, first on the scene, found the person unconscious in his home, tried to clear his airway, and called for emergency medical assistance.

The police officer didn't wear respiratory protection, but paramedics from the Oakland Fire Department and a local ambulance service did. In the emergency department, at least 10 people worked on the patient to save his life, including a respiratory therapist who assisted in the intubation.

By the next morning, Friday, Dec. 4, initial results from blood and cerebrospinal fluid indicated that the patient might have bacterial meningitis. That finding should have prompted an immediate call to the local public health officer, says Gold.

On Sunday, further blood testing confirmed N. meningitides but, again, that wasn't immediately reported, according to Cal-OSHA. The hospital contacted the Alameda County Public Health Department on Monday afternoon, Dec. 7, according to the citations, more than 78 hours after meningitis was first suspected.

That delay in reporting, along with two other previous cases of delayed reporting, led to a "willful" citation with a $5,000 fine. "There is a requirement of prompt notification of the health department so they can start contact tracing," says Gold. "Exposure investigations are much more effective when done promptly."

On Dec. 9, the police officer was admitted to Kaiser Permanente Walnut Creek Medical Center with meningitis; he spent five days in the hospital. On Dec. 10, the respiratory therapist was admitted to John Muir Medical Center in Walnut Creek; he remained hospitalized for 11 days.

On Dec. 11, Alta Bates Summit Medical Center conducted a belated exposure analysis and contacted potentially exposed employees, Cal-OSHA says. Two potentially exposed employees in the radiology department weren't notified until Dec. 15, and a charge nurse who had been in the emergency department when the patient was treated was never included in the exposure analysis or post-exposure evaluation and treatment, according to the citations.

Those failures triggered another "willful" citation with a fine of $70,000. Willful violations are defined as incidents in which "the employer knew hazards existed which could lead to serious physical harm or a fatality and took no action to correct the hazards and comply with the appropriate regulations," Cal-OSHA says.

Cal-OSHA also cited the hospital for an incomplete aerosol transmissible diseases exposure control plan, as well as incomplete fit-testing and training.

The Oakland Police Department also was cited for nine violations, including failing to notify the officer of his exposure, failing to provide a medical evaluation, and failing to inform the fire department or ambulance service. The Oakland Fire Department was cited for similar notification failures. All three employers were cited for failing to comply with the ATD standard.

The incident underscores the importance of prompt notification, evaluation and prophylaxis, says Gold.

"We're lucky that somebody didn't die. Both of the exposed employees had families with children at home. This could have had a worse outcome," she says. "But we had two employees hospitalized for a significant period of time with a life-threatening disease. It was probably preventable if they had been informed of their exposure and provided treatment."

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